2.0 Analysis 2.1 Decision to Abandon Ship in the Aluminium Boat It is not known why the crew of the SEA ALERT decided to abandon ship in the aluminium boat. Although the boat was positioned under the davit, the inflatable liferaft would have been quicker and easier to launch. It is also not known why the painter was not cut at the boat deck level instead of trying to free it at the main deck level. 2.2 Communications As more oil exploration and related maritime activity takes place in Labrador in general and in Voisey Bay in particular, the need for effective ship/shore radio communications increases. Effective communication with MCTS Centres in this region is provided by MF transmissions; there is no VHF coverage. Also, the MF radios that are currently required for vessels operating in this area can be used effectively for bridge-to-bridge communications. Although the lack of a shore-based VHF relay station made radio communications difficult among those involved in the SAR operation, it would not have precluded the other vessels known to have been within VHF range at the time of the occurrence from receiving a MAYDAY message from the SEA ALERT. Given how quickly the situation leading to the vessel's capsizing developed, it is unlikely that a MAYDAY was sent; none was heard. The vessel's float-free EPIRB, however, was heard to be transmitting at 1534, about 30 minutes after the vessel had struck Jenks Rock. Digital selective calling (DSC) capability increases the probability that a vessel in distress can send an alert and that it will be received. With this technology, alerts can be sent at the push of a button. The use of pre-formatted distress messages with position information ensures that essential information is included in the distress message. The SEA ALERT and the vessels within VHF range were not fitted with VHF R/Ts with channel 70 DSC capability, nor were they required to be. A DSC capability would have greatly improved the chance of a ship-to-ship alert being sent and successfully received. In addition, ships that fit a satellite terminal approved for Global Maritime Distress and Safety System (GMDSS) have the capability of worldwide (70N to 70S latitude), automated ship-to-shore distress alerting. The implementation of the GMDSS to domestic ships is currently being reviewed by TC Marine Safety, in consultation with the marine industry. 2.3 Flooding and Sinking Regulatory hull construction requirements for tugboats of this size and class do not call for the incorporation of double-bottom or side tanks and, consequently, these vessels are highly vulnerable in the event of extensive damage to the single-shell plating. Furthermore, with the exception of compliance with the flooding requirements of PartVIII of the HCR, there is no regulatory subdivision limitation restricting the length of any under-deck compartment. The engine-room of the SEA ALERT extended over nearly 60percent of her length, and post-casualty calculations based on the reported departure loading condition show that uncontrolled flooding of this compartment would have caused the vessel to settle and trim by the stern, downflood, lose reserve buoyancy, and sink stern first. The extent and precise location of the underwater damage is unknown, but the engine-room was observed to be flooding at a rate in excess of the vessel's total bilge-pumping capacity of 1,000L/min (16.67L/sec). The steady and sudden final heel to starboard would indicate that the initial ingress of flood water and principal underwater damage most likely were sustained on that side, and this is consistent with the sinking sequence reported by the survivor. 2.4 Significant Factors in the Striking There is nothing to suggest that there was a malfunction of the mechanical, electrical, or navigational instruments, or of the steering gear. Further, no distress message was received by any ship or shore station nor was a voyage plan from the master found. The only surviving crew member, a deck-hand who had limited experience, could not provide definitive information. Therefore, it is difficult to determine the precise sequence of events and circumstances that led to this occurrence. However, several observations by the survivor provided some useful insight regarding the actions of the master and the other crew members. In particular, his recall of the master's remark that the tug must be past the rock, when this was not the case, strongly suggests that the master had lost awareness of his vessel's exact position. It would appear that this loss of situational awareness led to the tug striking the rocky shoal. Situational awareness can be defined as all knowledge that is accessible and can be integrated into a coherent picture, when required, to assess and cope with a situation.(4)More simply, situational awareness is knowing what is going on around you.(5) The successful completion of a complex task such as navigation of a vessel depends upon situational awareness in both the development and implementation of plans and procedures. Situational awareness develops on three different levels. First, there has to be a perception of the situational elements derived from a variety of potential sources of information such as equipment displays, task-specific communication with others, and a view of the external environment. Next, the perceived information must be integrated into a meaningful context using one's personal experiences and knowledge. Finally, that information is then used to modify plans as the task progresses. Several factors may have contributed to the master's loss of situational awareness: 1) The master chose to follow an unfamiliar route (which was difficult in that it required frequent course alterations) while the tug proceeded at eight knots (a speed greater than her normal towing speed), without assistance from either of the two deck-hands. Both the route and the speed probably increased the workload associated with the navigation of the vessel. Since the master was the one involved in the navigation of the vessel, which included close monitoring of the tug's progress and speed using visual observation, radar information and GPS, and giving helm orders, it is likely that between course alterations he would have had limited time for information processing, decision making, and plan modification and execution. As the master had decided to transit the difficult route and to perform the navigation tasks alone, good nautical practices dictate that he should have reduced the tug's speed to afford himself more time to assess and respond to any developing situation. 2) The master was familiar with the general area and was aware of the limitations of the electronic navigation aids. As horizontal reference datum for the chart in use is unknown, positions obtained by GPS could have been in error by about one mile. Because of this limitation posed by the GPS, the master could not use it to verify the tug's position and, consequently, the GPS was used only as a speed log. 3) The master did not plot the vessel's position on the appropriate chart. Such plotting would have assisted him in better monitoring the vessel's progress. 4) The presence in the wheel-house of additional persons who--though acting responsibly--were not actively involved in operational tasks, may have distracted the master. The master had the conduct and the engineer was tasked to steer the tug. For BRM to be effective, it is essential that the personnel forming the bridge team be knowledgeable in the principles of navigation or have some navigational experience. The extent of the relevant knowledge and navigational experience of the deck-hands, or the contribution they may have been able to make to BRM, are not known. The master was generally a prudent and cautious navigator, but he did not employ the deck-hands' assistance in the navigation of the vessel. 3.0 Conclusions 3.1 Findings the relatively high speed of the vessel while navigating an unfamiliar and difficult route; the non-plotting of the tug's position on the chart; and the distraction associated with the presence of non-essential personnel in the wheel-house. the relatively high speed of the vessel while navigating an unfamiliar and difficult route; the non-plotting of the tug's position on the chart; and the distraction associated with the presence of non-essential personnel in the wheel-house. No bridge resource management (BRM) regime was in place to assist the master in the navigation of the tug. The flooding observed in the engine-room occurred at a rate in excess of the vessel's bilge pumping capacity. The vessel rolled onto her starboard beam-ends, downflooded, and sank by the stern. While attempting to free a fouled painter instead of cutting it, the master, engineer and deck-hand became trapped and are presumed to have drowned. The crew of the SEA ALERT first attempted to abandon ship in the aluminium boat rather than in the inflatable liferaft, which would have been quicker and easier to launch. It is unlikely that the vessel sent a MAYDAY message by very high frequency (VHF) radio. Search and Rescue (SAR) authorities were alerted by transmissions from the vessel's float-free Emergency Position Indicating Radio Beacon (EPIRB) about 30minutes after the vessel had struck the rocky shoal. In the area of increasing traffic where the vessel sank, there is no shore-based radio coverage for VHF transmissions. In the area of the sinking, positions obtained by electronic navigational systems, including by Global Positioning System (GPS), do not necessarily correspond to those obtained by bearing and distance when plotted on the chart, and warnings to that effect are printed on the relevant publications. 3.2 Causes The SEA ALERT, while navigating an unfamiliar and difficult route at full speed, struck a rocky shoal and sank due to an error in navigation probably associated with a loss of situational awareness. Contributing factors to the accident were the non-plotting of the tug's position and the absence of a bridge resource management regime. The presence of non-essential personnel on the bridge may also have been a contributing factor. 4.0 Safety Action 4.1 Action Taken Following this occurrence, the Canadian Coast Guard (CCG) sponsored a study, Requirements for CCG Services Along the Labrador Coast. The objective of the study, conducted by Consulting and Audit Canada(CAC), was to assess the requirements for CCG services along the Labrador coast in light of the current CCG levels of service (LOS), the current demand, and the expected economic developments bringing increased marine traffic to the area. The study evaluated the adequacy of CCG services, which include Aids to Navigation, Search and Rescue, Safety and Environmental Response, Marine Communications and Traffic Services, Ice Services, and the Navigable Waters Protection Act. The report identified several deficiencies in CCG LOS in the area, including the following: Only about 10 per cent of the Labrador coast is surveyed to modern standards, which does not allow for a safe marine transportation system. CCG services delivered along the Labrador coast meet neither national LOS standards nor the standard delivered to the rest of Newfoundland. The marine transportation system being provided along the Labrador coast may not be as safe and reliable as it is in other parts of Canada. The report was completed and published in May 1998, making 14 recommendations to improve CCG services along the Labrador coast regarding the state of hydrography, delivery of CCGservices, availability of reliable marine traffic data, and traffic density and routes. In accordance with CAC recommendations, the implementation plan for the Labrador Seaway Program includes a detailed study of additional CCG service requirements and further analysis of costs and priorities. The program includes additional hydrographic work to increase the coverage and accuracy of navigation charts near the main shipping routes. With regard to the need for 250 conventional aids to navigation, the CCG is looking at all opportunities to use surplus equipment from other regions. In 1998, 140 new navigational aids have been installed along the Labrador coast.